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Neuromuscular Training & ACL Injury Prevention: A Systematic Review Bialercowski, Christine; Campbell, Sean; Falkner, Sara; Owen, Jessica; Ward, Alex; MacIntyre, Donna; Dumont, Tyler 2006-10-05

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Neuromuscular Training & ACL Injury Prevention: A Systematic Review Presented by: Christine Bialkowski, Sean Campbell, Sara Falkner, Jessica Owen & Alexander Ward Supervisors: Donna MacIntyre & Tyler Dumont Outline z Introduction to ACL injuries z Purpose of our review zMethod z Results z Discussion z Conclusions z Questions An Introduction to ACL Injuries • ~70% are non-contact (Arendt et al., 1995) • Common mechanism = rapid deceleration (I.e. planting/cutting maneuvers or landing from a jump) • Females at higher risk than males (4-6x higher in soccer) (Mihata et al., 2006) Risk Factors zINTRINSIC: – Hormonal – Anatomical – Biomechanical – Neuromuscular zEXTRINSIC: – Bracing – Physical/visual perturbations – Shoe-surface interactions (Hewett et al., 2006) Neuromuscular Mechanisms z Unbalanced medial to lateral quadriceps ratio (Myer et al., 2005, Rozzi et al., 1999) z Pre-planned vs. unanticipated movements – Increased varus-valgus and internal-external rotation moments (Besier et al., 2001) z Quadriceps-hamstrings antagonist-agonist relationship – Deficits in strength and activation of hamstrings (Solomonow et al., 1987) – Decreased co-activation (F > M) (Hewett et al., 2006) (Petrus C, 2006) The Need For Prevention z ~95,000 new ACL injuries/year z If surgery is required – 6 to 24 months of rehab = $17,000/injury (Beynnon et al., 2005, Hewett et al., 1999) z ACL reconstruction does not ensure a return to previous activity levels (Fithian et al., 2002) z If left untreated Æ chronic knee instability, secondary joint damage and early OA (Andriacchi et al., 2006) Purpose of Our Review z Identify the effectiveness of neuromuscular training programs in the prevention of ACL injury in athletes participating in high risk sports METHOD Literature Search • English language • 1996 – August 2006 • MEDLINE, CINAHL, EMBASE, Web of Science, PubMed, SPORT Discus, CENTRAL and PEDro Common Search Strategy 1. Anterior cruciate ligament injur$ or ACL injur$ OR knee injur$ 2. Prevention 3. 1 AND 2 4. Neuromuscular OR exercise OR training OR balance OR proprioception OR agility OR plyometric$ 5. 3 AND 4 The Search continues… z Grey literature search (ProQuest Dissertations & Theses database) z Hand search (J. of Orthopedic and Sports Physical Therapy) z Reference list search of included articles z Contacted experts Study Selection Criteria 1) Subjects were male or female athletes participating in one or more of the identified high risk sports 2) The intervention was a neuromuscular training program aimed at preventing knee injury 3) An experimental design was used 4) Outcome measure was ACL injury incidence Exclusion Criteria Rehabilitation intervention post-ACL injury SPORTDiscus (n=208) EMBASE (n=46) CINAHL (n=96) PubMed (n=137) Cochrane Central Register of Controlled Trials (n=11) PEDro (n=179) Web of Science (n=59) Potentially relevant citations identified through electronic searches (n=736) Citations excluded after title screening (n=582) Abstracts retrieved for review (n=154) Studies excluded after abstract screening (n=109) Full articles retrieved for detailed review (n=45) Studies excluded after full text review (n=38) Relevant studies included in systematic review (n=7) Search Flow Diagram Review Criteria • Sackett’s levels of evidence as updated by Phillips et al. in the Oxford Centre for Evidence-based Medicine Levels of Evidence (Sackett, 1986, Phillips et al., 2001) Methodological Quality Criteria • Megens and Harris as modified by Medlicott and Harris (Megens et al., 1998, Medlicott et al, 2006) • 10 criteria • Strong (8-10); moderate (6 or 7); weak (5 or less) RESULTS Levels of Evidence • 5 non-randomized cohort studies • 2 randomized cohort studies • All studies used prospective data collection methods • All identified as level IIb Methodological Rigor • Range 3 to 7 (out of 10) • Mean score = 6 • Median score = 7 • 5 studies scored as “moderate” and 2 as “weak” Methodological Rigor Authors Mandelbaum et al (2005) Hewett et al. (1999) Myklebust et al. (2003) Soderman et al. (2000) Petersen et al. (2005) Caraffa et al. (1996) Heidt et al. (2000) Randomization N N N Y N N Y Inclusion/ Exclusion criteria Y Y Y Y Y Y Y Similarity of groups at baseline Y N Y Y Y Y N Replicability Y Y N Y N N N Reliability Y Y Y N Y Y N Validity Y Y Y N Y Y N Blinding N N N N N N N Dropouts N Y Y Y Y N N Long-term results Y Y Y Y Y Y Y Adherence Y Y Y Y N N N Total score /10 7 7 7 7 6 5 3 Rigor rating Moderate Moderate Moderate Moderate Moderate Weak Weak 10 Criteria for Methodological Rigor 1) Randomization: • 2 of the 7 studies randomly assigned subjects to an intervention or control group 2) Subject Inclusion and Exclusion Criteria: • High school to semi-professional athletes • Exclusions: Poor compliance; previous knee injury; geography • 6 studies targeted females; 1 study targeted males 3) Similarity of Groups at Baseline: • 5 studies reported similarities (I.e. height, weight, age, muscle flexibility, balance/ postural sway of lower extremities, sport experience) 4) Replicability of the Treatment Protocols: • Must have been stated within the article or have had an accessible reference • Mandelbaum et al., Hewett et al., and Soderman et al. provided this 5) Outcome Measure Reliability: • MRI or arthroscopy for diagnosis • 5 studies met this criteria 6) Outcome Measure Validity: • Valid if used MRI or arthroscopy for diagnosis • Therefore, 5 studies also met this criteria 7) Blinding Assessment: • Must have blinded the subjects, treatment provider AND assessor • No study met this criteria 8) Reporting of Dropouts: • Peterson et al., Hewett et al., Mykelbust et al., and Soderman et al provided sufficient detail 9) Long Term Follow-Up: • All studies were carried out over at least one season (> 6 months) 10) Adherence to Intervention Program: • Unreported in Caraffa et al. and Heidt et al. THE STUDIES Caraffa et al. (1996) Study Design Prospective cohort Rigor & Level of Evidence 5 (“weak”) & IIb Duration 3 seasons Target Population Semi professional and amateur male soccer players Sample Size 300 Intervention; 300 Control Caraffa et al. (1996) Intervention • Progressive balance board training, stepping exercises, and “neuromuscular techniques” • 20 min/day every day during preseason, 3x/week during active season Supervision? Coaches Compliance Not reported Incidence • 10 Intervention (0.15/team/year) • 70 Control (1.15/team/year) Program Recommended? Yes - Significant difference was found between intervention and control groups Heidt et al. (2000) Study Design Randomized Cohort Rigor & Level of Evidence 3 (“weak”) & IIb Duration 1 season Target Population Female high school soccer players (ages 14-18yrs) Sample Size 42 Intervention; 258 Control Heidt et al. (2000) Intervention • 7 week preseason  program including cardiovascular, plyometrics, strength, and flexibility training (20 sessions) • 2x/week speed training treadmill sessions where grade was elevated • 1x/week plyometric session that progressed throughout 7 weeks from unidirectional to multidirectional to floor obstacles Supervision? Not reported Compliance Not reported Incidence • 1 Intervention (2.4%); 8 Control (3.1%) Program Recommended? • Yes - Significant decrease in lower extremity injuries found between intervention and control groups • No significant difference in incidence of ACL injuries – authors attribute this to small sample size Hewett et al. (1999) Study Design Prospective cohort Rigor & Level of Evidence 7 (“moderate”) & IIb Duration 1 season Target Population Female high school soccer, volleyball, and basketball players Sample Size 366 Intervention (female); 897 Control (434 males; 463 females) Hewett et al. (1999) Intervention • 6 week preseason jump training program; flexibility, plyometrics, and weight training • 3x/week, 60-90 min/day, total of 18 sessions Supervision? Athletic trainer, coaches, physical therapist Compliance 70% completed 6 week program Incidence • 2 Intervention; 6 Control (1 male, 5 female) incidence of all knee injuries • 0.43 female control, 0.12 female intervention, 0.09 male control Program Recommended? Yes - The untrained group had a knee injury rate 3.6 times higher than the female intervention group and 4.8 times higher than the male control group. Mandelbaum et al. (2003) Study Design Prospective cohort Rigor & Level of Evidence 7 (“moderate”) & IIb Duration 2 years Target Population Amateur female soccer players (ages 14-18 yrs) Sample Size • 2000: 1041 Intervention; 1905 control • 2001: 844 Intervention; 1913 Control Mandelbaum et al. (2003) Intervention 20 min warm up prior to practices and games: 3 warm-up techniques, 5 stretches, 3 strengthening ex’s, 5 plyometric ex’s, 3 soccer specific agility drills Supervision? Coaches Compliance • 2000: 96.15%; 2001: 100% Incidence • 2000: 2 Intervention  (0.05/athlete/1000 exposures); 32 Control (0.47/athlete/1000 exposures) • 2001: 4 Intervention (0.13/athlete/1000 exposures); 35 Control (0.51/athlete/1000 exposures) Mandelbaum et al. (2003) Program Recommended? Yes - Significant difference was found between intervention and control groups with 88% reduction/athlete in 2000 season and 74% reduction/athlete in 2001 season Myklebust et al. (2003) Study Design Prospective cohort Rigor & Level of Evidence 7 (“moderate”) & IIb Duration 3 seasons (1 control; 2 intervention seasons) Target Population Female handball players Sample Size • 1998/99: Control Season 942 • 1999/2000: Intervention Season 855 • 2000/01: Intervention Season 850 Myklebust et al. (2003) Intervention • 15 min circuit of floor ex’s, wobble board ex’s, balance mat ex’s • 3x/week during 5-7 week training period then 1x/week during season Supervision? Coaches in first season, physiotherapists in second season Compliance • 1999/2000: 26% of teams fulfilled compliance criteria (42% elite division) • 2000/01: 29% of teams fulfilled compliance criteria (50% elite division) Myklebust et al. (2003) Incidence • Control season: 29 (0.14/1000 player- hours) entire cohort, 13 elite division • First Intervention season: 23 (0.13/1000 player-hours) entire cohort,6 elite division • Second intervention season: 17 (0.09/1000 player -hours) entire cohort, 5 elite division Program Recommended? Yes - Although no significant difference was found between intervention and control seasons across the entire cohort, there was a significant difference between those who completed the program and those who didn’t in the elite division Petersen et al. (2005) Study Design Prospective cohort Rigor & Level of Evidence 6 (“moderate”) & IIb Duration 1 season Target Population Semi-professional and amateur female handball players Sample Size 134 Intervention; 142 Control Petersen et al. (2005) Intervention • Six phase balance board and jump exercise program • 3x/week preseason (8 weeks), 1 x week competitive season 10 min/ session Supervision? Coaches Compliance Not reported Incidence 1 Intervention (0.04/1000 hours exposure*); 5 Control (0.21/1000 hour exposure) Program Recommended? Yes - Although no significant difference was found between intervention and control groups Soderman et al. (2000) Study Design Randomized cohort Rigor & Level of Evidence 7 (“moderate”) & IIb Duration 1 season Target Population Female soccer players (2nd and 3rd Swedish Divisions) Sample Size 62 Intervention; 78 Control Soderman et al. (2000) Intervention • Balance board exercises each day for 30 days, then 3x/week for remainder of season • 10-15 min/ session Supervision? Self – home program Compliance 70% Incidence 4 Intervention; 1 Control Program Recommended? • No - Significantly higher incidence rate of major injuries found in intervention group • No significant difference in minor and moderate injuries was found between intervention and control groups DISCUSSION & IMPLICATIONS Methodological Rigor & Levels of Evidence z Rigor and levels of evidence were moderate zMajor contributors to low quality: – Randomization – Blinding z Nature of study designs makes these difficult Intervention Characteristics z Phase of implementation: – Pre-season – Competitive season z Type of intervention: – Balance/proprioception – Strength – Agility – Flexibility – Plyometrics – Combination z Other training parameters (i.e. frequency, duration, progression, etc.) Significance z All studies except 1 found a decrease in incidence of ACL injury – Soderman et al. showed a trend towards an increase in ACL injury in the intervention group z Caraffa et al., Hewett et al., and Mandelbaum et al. found statistically significant differences z Myklebust et al. found a significant difference between intervention and control groups only in the elite handball division Implications for Clinical Practice 1) There is moderate evidence to support the use balance/proprioceptive training in ACL injury prevention. Implications for Clinical Practice 2) There is moderate evidence to support the use of plyometric training in combination with other training components injury prevention of ACL injury. Implications for Clinical Practice 3) There is promising evidence that balance/proprioception training, strength training and plyometric training when incorporated into a comprehensive training protocol may be effective in reducing the incidence of ACL injury. - Details insufficient Implications for Clinical Practice 4) There is moderate evidence that training implemented in the preseason and/or competitive season is effective for ACL injury prevention. Challenges in Drawing Conclusions z Quality of studies z Lack of program details z Compliance z Heterogeneity: – Intervention parameters – Subjects – Duration Implications for Future Research z Isolation of program components zMore rigorous studies z Careful documentation to allow replicability of training programs zMonitoring and reporting compliance z Intervention parameters need to be established z Effect of interventions on age and gender Limitations of Our Review z Only used publications in English z Lack of correspondence from experts z Only used articles accessible free of charge to UBC students QUESTION PERIOD Thank you for your attention! REFERENCES Andriacchi TP, Briant PL, Bevill SL, Koo S. Rotational changes at the knee after ACL injury cause cartilage thinning. Clinical Orthopaedics & Related Research 2006;442:39-44. Arendt E, Dick R. Knee Injury Patterns among Men and Women in Collegiate Basketball and Soccer. NCAA Data and Review of Literature. Am J Sports Med 1995;23:694-701. Besier TF, Lloyd DG, Ackland TR, Cochrane JL. Anticipatory effects on knee joint loading during running and cutting maneuvers. Med Sci Sports Exerc 2001;33:1176-1181. Caraffa A, Cerulli G, Projetti M, Aisa G, Rizzo A. Prevention of anterior crucuate ligament injuries in soccer; A prospective controlled study of proprioceptive training. Knee Surg, Sports Traumatol, Arthrosc 1996;4:19-21. Fithian DC, Paxton LW, Goltz DH. Fate of the anterior cruciate ligament-injured knee. Orthopedic Clinics of North America 2002;33. Heidt RS, Sweeterman LM, Carlonas RL, Traub JA, Tekulve FX. Avoidance of Soccer Injuries with Preseason Conditioning. American Orthopaedic Society for Sports Medicine 2000;28:659-662. Hewett T, Myer G, Ford F. Anterior cruciate ligament injuries in female athletes. Part 1, Mechanisms and Risk Factors.  Am J Sports Med 2006;34:299-311. Hewett TE, Lindenfeld TN, Riccobene JV, Noyes FR. The effect of neuromuscular traiing on the incidence of knee injury in female athletes. A prospective study.  Am J Sports Med 1999;27:699-706. Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin, LY, Kirkendall DT, Garrett W. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med 2005;33:1003-1010. Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Phys Ther 2006;86:955-975. Megens A, Harris SR. Physical therapy management of lymphedema following treatment for breast cancer: a critical review of its effectiveness. Phys Ther 1998;78:1302-1311. Mihata L, Beutler A, Boden B. Comparing the incidence of anterior cruciate ligament injury in collegiate lacrosse, soccer and basketball players.  Implications for anterior cruciate ligament mechanism and prevention.  Am J Sports Med 2006;34:899-904. Myer GD, Ford KR, Hewett TE. The effects of gender on quadriceps muscle activation strategies during a maneuver that mimics a high risk ACL injury position. J Electromyogr Kinesiol 2005;15:181-189. Myklebust G, Engebretsen L, Braekken IH, Skjolberg A, Olsen OE, Bahl R.  Prevention of Anterior Cruciate Ligament Injuries in Female Team Handball players: A Prospective Intervention Study Over Three Seasons. Clinical Journal of Sports Med 2003: 13;71-78. Petersen W, Braun C, Wiebke B, Schmidt K, Weimann A, Drescher W, Eiling E, Stange R, Fuchs T, Hedderich J, Zantop T. A controlled prospective case control study of a prevention training program in female team handball players: the German experience. Arch Orthop Trauma Surg 2005;125:614-621. Phillips B, Ball C, Sackett D, Badenoch D, Straus S, Haynes B, Dawes M. 2001. Levels of Evidence and grades of recommendation. Centre for Evidence Based Medicine. 2006 June-August [cited 2006 September 12]. Available from: URL: Rozzi SL, Lephart SM, Gear WS, Fu FH. Knee joint laxity and neuromuscular characteristics of male and female soccer and basketball players. Am J Sports Med 1999;27:312-319. Sackett DL. Rules of evidence and clinical recommendations on use of antithrombotic agents. Chest 1986;89:2S-3S. Soderman K, Werner S, Pietila T, Engstrom B, Alfredson H. Balance board training: prevention of traumatic injuries of the lower extremities in female soccer players? A prospective randomized intervention study. Knee Surg, Sports Traumatol, Arthrosc 2000;8:356-363. Solomonow M, Baratta R, Zhou BH, Shoji H, Bose W, Beck C, D'Ambrosia R. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med 1987;15:207-213.


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